Opinion: The ongoing measles outbreak was 'avoidable.' Now what?

Map by Sarah Milotte, The Rural Index via The Daily Yonder

As measles cases in the U.S. top more than 1,000 diagnosed infections, medical experts Richard Hughes and Anna Larson call the ongoing outbreak "an avoidable public health failure," in their opinion for MedPage Today.

Measles was declared "eliminated" in the United States in 2000, but its status is evolving. The most recent eruption of the highly contagious disease began in rural Texas and "continues to unfold with additional deaths in Texas and New Mexico, an exposure at a major U.S. airport following an identified case in Maryland, and expanding to over half of U.S. states," Hughes and Larson write.

The newly appointed Secretary of Health and Human Services, Robert F. Kennedy Jr., has added to the confusion about the measles, mumps and rubella (MMR) vaccine by endorsing "unproven treatments for measles and emphasizing vaccination as a personal choice rather than a public good," they write. When "he finally recommended measles vaccination to address the snowballing case count, he then ordered the search for new measles treatments instead of promoting vaccination."

Searching for a new measles "cure" won't stop the continuing spread of the disease, but beefing up MMR vaccine rates could. Instead, the administration "has canceled research related to vaccine hesitancy and misinformation," Hughes and Larson add, "and announced a requirement that all new vaccine products undergo placebo-controlled clinical trials prior to licensure."

What is likely to happen? "We can expect vaccination challenges to compound, immunization rates to decline, and vaccine-preventable diseases to rise," Hughes and Larson write. "A comprehensive U.S. approach to shore up our measles defenses and preserve elimination status is imperative, but unlikely."

What can be done to slow the current measles outbreak down? "Consistent application of proven public health measures -- expanded vaccine access, particularly in underserved populations, and improved disease and vaccine surveillance systems," according to Hughes and Larson. "The need to combat misinformation and instill public trust in vaccines is obvious, but bears repeating. . . . Now is not the time for complacency; it's time for action."

Alabama agrees to provide sewage-disposal systems to a county, in first-of-its-kind settlement agreement with feds

Sewage overflow in Lowndes County (Photo: Dennis Pillion, AL.com)

Do all Americans have a right to sanitation even if they cannot afford the systems needed to do the job? "The federal government now seems to be answering yes to that question, using a civil-rights investigation to press Alabama to solve long-standing sewage infrastructure problems in remote and lightly populated areas," reports Dennis Pillion of AL.com.

The Justice Department alleged that the Alabama Department of Public Health "engaged in a consistent pattern of inaction and/or neglect concerning the health risks associated with raw sewage" in Lowndes County, a rural, majority-Black county of about 10,000 people. Now Alabama "is the first state to reach an interim settlement agreement with federal authorities on environmental-justice grounds," agreeing to provide the county with adequate sewage treatment. The Environmental Protection Agency defines environmental justice as "the fair treatment and meaningful involvement of all people regardless of race, color, national origin, or income, with respect to the development, implementation, and enforcement of environmental laws, regulations, and policies."

Lowndes County
(Wikipedia map)

Widespread poverty is one reason Lowndes County has been unable to resolve its sanitation challenges. The second obstacle is its very dense Black Belt soil, which "makes many septic systems inoperable," Pillions notes. "Addressing the wastewater needs of each residence in Lowndes County will likely require treatment systems of all different shapes, sizes and technologies [and many millions of dollars, but just how much is still a huge question. . . . Much of the cost will come from federal funds. The agreement stipulates that ADPH should seek funding from the American Rescue Plan Act and other federal grants to conduct its analysis and create an action plan to solve these sewage issues. ADPH will collaborate with the Centers for Disease Control and other federal agencies throughout the project."

Some rural areas reject federal money, citing overreach of federal agency and government mistrust

Elko County (Wikipedia)

Elko County, Nevada, has not had a public health department for more than 15 years, but county commissioners rejected a $500,000 grant from the Centers for Disease Control and Prevention "citing concerns about government overreach. Commissioners and members who opposed the grant said Elko didn’t need more public health resources or a health district or department. They said they were concerned about giving up local autonomy and growing bureaucracy. They also expressed mistrust of the CDC," reports Jazmin Orozco Rodriguez of Kaiser Health News.

Elko County wasn’t the only one who refused to pursue federal aid. "Experts say they were surprised and concerned to see the rare local or state leader, swayed by political partisanship, dismiss funding opportunities for historically limited public health systems," Rodriguez writes. "Officials in Idaho, Iowa, and New Hampshire rejected Covid relief money, their decisions often accompanied by political pronouncements about federal government overreach. . . . A survey of local governments in 15 states conducted by the National League of Cities found more than 200 small governments declined pandemic relief funds."

The Elko County commissioners received letters from health officials and pleas from residents at public meetings asking them to accept the federal money. "Other local leaders saw the need for increased public health resources amid the pandemic. The Elko City Council wrote a letter of support for the CDC grant the day before the commission rejected it," Rodriguez reports.

“Partisan politics has poisoned the well to a point that we’re willing to sacrifice the health of our citizens,” said Brian Castrucci, president and CEO of the de Beaumont Foundation, a national nonprofit that advocates for public health policy. “Is the political grandstanding worth it?”

Adriane Casalotti, chief of government and public affairs for the National Association of County and City Health Officials, told Rodriguez, "Communities across the country have generally clamored for increased funding during the pandemic, which strained already underfunded and understaffed public health infrastructure. In recent months, I’d say, we’ve heard of a handful of health departments that either would not apply for or couldn’t accept … specific grants."

Polarization remains an obstacle, Castrucci told Rodriguez: "This has become a holy war, this has become a war of right and wrong. I don’t know how to get through that to a place where we are prioritizing the health of our nation.”

Health department prevention specialist in Wyoming works to reduce rural stigma on seeking help for mental health

Johnson County in Wyoming (Google map)

On paper, Bill Hawley "is the 'prevention specialist' for the public health department in Johnson County, a plains-to-peaks frontier tract in Wyoming that is nearly the size of Connecticut but has a population of 8,600 residents. His official mandate is to connect people who struggle with alcohol and drug abuse, tobacco addiction, and suicidal impulses to the state’s limited social service programs. Part bureaucrat, part counselor, much of Bill’s life revolves around Zoom calls and subcommittees, government acronyms and grant applications," Jose Del Real reports for The Washington Post. "But his mission extends beyond the drab county building on Klondike Drive where he works. One Wyoming man at a time, he hopes to till soil for a new kind of American masculinity."

Hawley knows that men overall and rural men in particular face intense pressure to be stoic, that stigma of needing mental-health care often prevents them from seeking it. But men accounted for 79% of suicide deaths in the U.S. in 2020, and 70% were white men. Most of those suicides involved firearms, and often involved alcohol or drugs, Del Real reports. The phenomenon is particularly bad in Wyoming, which has the highest suicide rate per capita in the nation. 

Sociologists believe toxic masculinity may be to blame, and that rural stigma can make things even worse. Hawley, "who is 59 years old and White, is working out his own theory. It has to do with the gap between the expectations men have for their lives and the reality of their individual experiences, worsened by cultural norms that discourage them from expressing any emotions besides anger," Del Real reports. "Toxic masculinity often turns outward. But it also turns inward."

Syringe program restrictions led to severe HIV outbreak in rural W.Va.; state often leaves local health depts. in the dark

Most residents of West Virginia now live more than 75 miles from a
sterile-syringe program. (Graphic by The Guardian; click on it to enlarge)

West Virginia is seeing a severe outbreak of the human immunodeficiency virus (HIV) that causes AIDS, spurred by state restrictions on clean-syringe programs for intravenous drug users, The Guardian reports. The problem may be particularly severe in rural areas, which now have even less access to the programs.

"Kanawha County, where Charleston is the seat, diagnosed 40 people who inject drugs with HIV in 2020, about as many as New York City, a place 47 times more populous," Jessica Glenza reports. "Last year, the head of HIV prevention at the Centers for Disease Control and Prevention warned Kanawha had the nation’s 'most concerning' outbreak of HIV among injection drug users." Cases began rising there in 2018 after the city restricted syringe programs. Soon afterward, nearby Huntington, then the state, followed suit. Since 2018, nearly half of such programs in the state shut down.

"The new law requires programs to offer a range of health services in addition to the exchange, only serve people with a West Virginia ID card, and aim to get one used syringe back for each new one they give out," Quenton King reports for Mountain State Spotlight.

Glenza reports, "The restrictions mean that almost 1 million people in West Virginia, the state with the highest drug overdose rate in the U.S. for nine years running, now live between 20 and 75 miles of the nearest needle exchange. Meanwhile, experts worry HIV is spreading undetected in rural West Virginia, where testing and treatment is limited."

However, it's difficult to assess the impact of HIV in rural areas: To preserve patients' privacy, the state's health department only releases ballpark numbers, King reports. That means even county health departments are in the dark about the local extent of the problem, and they are generally left out of the loop on HIV cases.

Robin Pollini, a substance-abuse and infectious-disease epidemiologist at West Virginia University, "says that it should be considered a significant concern when HIV appears in any county that previously had no cases, but especially in rural counties where access to care is limited," King reports. "There are actions that counties can take — from ramping up testing to creating harm reduction programs — by just knowing the number of HIV cases popping up in the county."

But local agencies might have a difficult time responding even if they knew about new cases. "With the current landscape — stressed by Covid, underfunded, and with new laws restricting the types of harm reduction programs they can offer — county health departments have few opportunities to address potential outbreaks, even if they see them coming," King.

Pandemic roundup: Extension services try to build rural trust in vaccines; former skeptics include a weekly publisher

Here's a roundup of recent news about the pandemic and immunization efforts:

Getting more people vaccinated against the coronavirus will require building trust, so cooperative extension programs across the U.S. are trying to do just that. In June the Extension Foundation announced a federally funded initiative to educate rural and other underserved areas about vaccinations. This story zeroes in on one extension service's efforts in the Black-majority town of Cairo, Illinois. Read more here.

President Biden has ordered the Education Department to take action against governors who ban school mandates. Read more here.

As the coronavirus surges in Florida, some rural vaccine skeptics change their minds, including Roger West, co-owner of the weekly Westside Journal near Jacksonville, Fla. Read more here.

An interactive map shows the percentage of hospital beds in each county occupied by Covid-19 patients. Read more here.

This map shows, by hospital referral regions, where intensive care unit beds are nearly full of Covid-19 patients. Categorizing it by referral region makes it particularly relevant to rural interests. Read more here.

Alabama has no more ICU beds available, state authorities say. Read more here.

Even with the vaccination rate higher than ever, fewer American adults feel confident that they won't become infected with the coronavirus, according to a new Gallup survey. Read more here.

Small incentives go a long way in getting people vaccinated, found a Colorado tourism town whose business owners banded together to offer coupons and other incentives to vaccinated customers. Read more here.

Most private insurers will no longer waive patients' share of Covid-19 hospital bills. Read more here.

It feels a little on the nose, but: August is National Immunization Awareness Month. Read more here for free content, tools, links, and more.

The Centers for Disease Control and Prevention has a guide to advocating for vaccines in one's community and online, and how to encourage more trust in health departments. Read more here.

The CDC also has a guide to addressing misinformation on social media. Read more here.

Public-health workers, once an 'invisible army,' have become 'a public punching bag' in a politicized pandemic

Karen Koenemann quit as public health director for Pitkin County, Colo. (seat: Aspen) after realizing she was in “Groundhog Day,” she said. “I have been working eight months, 12 hours a day, seven days a week. I’m really burnt out, really burnt out. ... I think of the pandemic as the ultra-marathon that we were required to do at a sprint’s pace. And we walked into that ultra-marathon emaciated, we didn’t train well for it, we didn’t have the strength going in. ... Every day I do the best I can and I am giving so much, so much of myself to this job and this community, and all I get is criticism and it just was like, ‘Why am I doing this?’ Life is too short.”  (Photo for Kaiser Health News by Kelsey Brunner)

Local and state public-health officials and workers are "at the center of a political storm as they combat the worst pandemic in a century," Kaiser Health News and The Associated Press report.

"Amid a fractured federal response, the usually invisible army of workers charged with preventing the spread of infectious diseases has become a public punching bag. Their expertise on how to fight the coronavirus is often disregarded," write Anna Maria Barry-Jester, Hannah Recht and Lauren Weber of KHN and Michelle R. Smith of AP.

Kaiser Health News map; to enlarge, click on it.

"Some have become the target of far-right activists, conservative groups and anti-vaccination extremists, who have coalesced around common goals — fighting mask orders, quarantines and contact tracing with protests, threats and personal attacks. The backlash has moved beyond the angry fringe. In the courts, public health powers are being undermined. Lawmakers in at least 24 states have crafted legislation to weaken public health powers, which could make it more difficult for communities to respond to other health emergencies in the future."

“What we’ve taken for granted for 100 years in public health is now very much in doubt,” Lawrence Gostin, a public-health law expert at Georgetown University, told one of the reporters.

It's too much for some in public health. "At least 181 state and local public health leaders in 38 states have resigned, retired or been fired since April 1," according to the reporters' ongoing investigation. "According to experts, this is the largest exodus of public health leaders in American history. An untold number of lower-level staffers has also left. . . . Many of the state and local officials left due to political blowback or pandemic pressure. Some departed to take higher-profile positions or due to health concerns. Others were fired for poor performance. Dozens retired."

“I’ve never seen or studied a pandemic that has been as politicized, as vitriolic and as challenged as this one, and I’ve studied a lot of epidemics,” Dr. Howard Markel, a medical historian at the University of Michigan, told one of the reporters. “All of that has been very demoralizing for the men and women who don’t make a great deal of money, don’t get a lot of fame, but work 24/7.”

"The politicization has put some local governments at odds with their own health officials," KHN and AP report, giving several examples. "In California, near Lake Tahoe, the Placer County Board of Supervisors voted to end a local health emergency and declared support for a widely discredited “herd immunity” strategy, which would let the virus spread. . . . The supervisors also endorsed a false conspiracy theory claiming many Covid-19 deaths are not actually from Covid-19. The meeting occurred just days after county Public Health Officer Dr. Aimee Sisson explained to the board the rigorous standards used for counting Covid-19 deaths. Sisson quit the next day."

Wednesday webinar to discuss CDC public-health worker training program that can help rural health departments

The Rural Health Information Hub will host a free webinar at 1 p.m. ET Wednesday, Dec. 2, to discuss the Public Health Associates Program and how it can benefit rural health departments. 

The PHAP is a two-year, paid training program through the Centers for Disease Control and Prevention in which public-health workers gain real-world experience working at public-health agencies and nongovernmental organizations around the country. 

Rural health departments may benefit from becoming a PHAP host site, especially since it's often difficult to find qualified health-care workers. The webinar will discuss PHAP's mission, goals and more. Interested organizations can apply to become a PHAP host site from Dec. 15 to Feb. 16.

Click here for more information about the webinar or to register.

Investigation shows how pork-processing plant officials sacrificed worker safety for profits during pandemic

Meatpacking plants have been a major vector for the coronavirus pandemic in rural areas. An investigation into an outbreak at Triumph Foods in St. Joseph, Missouri, shows how the company failed to enact appropriate safeguards that would have mitigated the spread of the disease, even as company officials said they were doing all they could to protect workers. Though St. Joseph is not rural (the population tops 76,000), the Triumph Foods investigation likely illustrates why other meatpacking plants have been coronavirus hotbeds.

The investigation is by Rachel Axon, Kyle Bagenstose and Kevin Crowe of USA Today and Sky Chadde of the Midwest Center for Investigative Reporting. The project receives funding from the Pulitzer Center on Crisis Reporting.

"The reporting found Triumph failed to respond with effective safeguards during a crucial period from mid-March to mid-April that could have contained the spread of covid-19. And local health officials, who received complaints from employees and their family members, missed several opportunities to investigate. They instead took the company’s word that it was doing all it could to protect its workers," Axon, Bagenstose, Crowe and Chadde report. "At the start of the pandemic, Triumph Foods employees worked up to 10 hours a day, crammed side by side. Even after the U.S. Centers for Disease Control and Prevention recommended the general public wear face masks, the company did not require them for weeks. It initially did not screen sick employees and implemented a bonus program that rewarded workers for perfect attendance even as they complained and fell ill."

The findings buttress experts' warnings that meatpacking plants would prioritize production over worker safety. "Workers and their unions have accused companies of doing the bare minimum to protect staff and time and again finding ways to keep their lines running," they report.

Rural county's entire health department staff resigns over lack of support from county government during pandemic

Pondera County, Montana
(Wikipedia map)

The Pondera County Health Department in Montana has four employees, and all of them have resigned in desperation, citing lack of support from the county commissioners during the pandemic, Liz Carey reports for The Daily Yonder. The move, effective Nov. 27, would leave a gaping hole in the local health-care system that would be hard to fill as coronavirus cases surge in the county of just over 6,000.

Nicki Sullivan, who was the department's director, wrote in her resignation letter that the decision was the hardest of her life, and that helping families brings her joy. But "Sullivan said she was most concerned with the commissioners’ lack of support for her and her department," Carey reports. "In her letter, she cited the lack of help doing contact tracing and being able to hire people to fill positions that would help with contact tracing.

The decision wasn't out of the blue: Sullivan sent the commissioners a letter Oct. 29 saying they needed to address issues that made her job impossible, and if they did, she would "consider staying." Otherwise, she implied that she would leave, and said it would be difficult for the next director to do a good job unless the commissioners address the problems, Carey reports.

Between Oct. 20 and Nov. 2, the other three employees resigned in solidarity, also effective Nov. 27, Carey reports.